What is the management for a 11-week pregnant woman with vaginal spotting, lower abdominal pain, and an ultrasound showing a gestational sac with no evidence of embryo or heartbeat?

Management of Anembryonic Pregnancy at 11 Weeks

This patient has an anembryonic pregnancy (also called a "blighted ovum") that requires definitive management through one of three options: expectant, medical, or surgical management, with the choice depending primarily on patient preference, hemodynamic stability, and desire for rapid resolution. 1

Diagnostic Confirmation

At 11 weeks gestational age with only a gestational sac visible and no embryo or heartbeat, this is definitively a pregnancy loss—not a case requiring follow-up imaging. 1

• A gestational sac ≥25 mm in mean diameter without a visible embryo is diagnostic of anembryonic pregnancy, and at 11 weeks from last menstrual period, the gestational sac would far exceed this threshold. 2, 1
• The absence of an embryo at this advanced gestational age eliminates any possibility of dating error or a viable pregnancy that is simply "too early" to visualize. 1
• At 11 weeks, an embryo with cardiac activity should be clearly visible on ultrasound if the pregnancy were viable. 1

Critical pitfall to avoid: Do not order repeat ultrasound "just to be sure" at this gestational age—this only delays necessary treatment and prolongs patient distress. 1

Immediate Assessment

Before discussing management options, assess:

• Hemodynamic stability: Check vital signs, particularly blood pressure and heart rate, to rule out significant hemorrhage. 2
• Severity of bleeding: Quantify whether bleeding is light spotting versus heavy hemorrhage requiring urgent intervention. 2
• Pain severity: Assess if pain suggests complications like infection or retained products. 2
• Rule out ectopic pregnancy: Although the presence of an intrauterine gestational sac makes ectopic pregnancy extremely unlikely in spontaneous conception, the adnexa should still be evaluated on ultrasound. 2

Management Options

Present all three options to the patient with their respective risks and benefits, as patient preference is paramount when she is hemodynamically stable. 1

Option 1: Expectant Management

• Allows spontaneous passage of pregnancy tissue without intervention. 1
• May take days to weeks for complete expulsion. 1
• Best for: Patients who prefer to avoid medications or procedures and can tolerate uncertainty about timing. 1
• Contraindications: Hemodynamic instability, signs of infection, patient preference for rapid resolution. 1

Option 2: Medical Management

• Typically involves misoprostol administration to induce uterine evacuation. 1
• Vaginal misoprostol 800 mcg is more effective than oral dosing for uterine evacuation of early pregnancy failure. 3
• Success rates are generally high for first-trimester losses, with complete abortion rates of 86% when absence of gestational sac on follow-up ultrasound is used as the success criterion. 4
• Best for: Patients who want to avoid surgery but desire more predictable timing than expectant management. 1
• Expected side effects include vaginal bleeding (mean 9 days), lower abdominal pain (mean 6 days), and possible gastrointestinal symptoms like diarrhea. 4

Option 3: Surgical Management

• Dilation and curettage (D&C) or manual vacuum aspiration provides immediate, definitive treatment. 1
• Best for: Patients desiring rapid resolution, those with contraindications to medical management, or those with significant bleeding. 1
• Offers the advantage of immediate completion and tissue for histologic confirmation. 1

Important caveat: Before proceeding with surgical evacuation, ensure the gestational sac is truly intrauterine and not an ectopic pregnancy masquerading as a missed miscarriage, as rare cases of abdominal ectopic pregnancies have been misdiagnosed as intrauterine losses. 5

Terminology and Patient Communication

• Use the term "early pregnancy loss" or "anembryonic pregnancy" when counseling the patient, avoiding outdated and insensitive terms like "blighted ovum," "pregnancy failure," or "nonviable pregnancy." 1
• Document the mean sac diameter measurement precisely in the medical record. 1

Follow-Up Protocol

If Expectant or Medical Management Chosen:

• Schedule follow-up ultrasound in 1-2 weeks to confirm complete passage of tissue. 1
• Instruct patient to monitor for signs of infection (fever, foul-smelling discharge), hemorrhage (soaking more than 2 pads per hour for 2 consecutive hours), or hemodynamic instability (dizziness, syncope). 1
• Success is best defined by absence of gestational sac on follow-up transvaginal ultrasound, which is associated with the highest short and long-term success rates. 4

If Surgical Management Chosen:

• Confirm complete evacuation and monitor for immediate complications. 1
• Tissue should be sent for histologic confirmation. 1

Additional Considerations

• Provide emotional support and acknowledge the loss, as this is a significant event for the patient. 1
• Discuss future pregnancy planning when appropriate, including timing of attempting conception again. 1
• Consider Rh status and administer RhoGAM if patient is Rh-negative. (General medical knowledge)